HomeMy WebLinkAbout20150923 JorgensonAgency Accident Number
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Reportable Accident On Emergency Amended GZDKSV9
DOT Document Number Document Override Number
15092611
15
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9
2
6
1
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09/26/2015
4 - Accident Date
2325
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County BASS LAKE - 01, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
HIGHLINE RD
14 - On Street Name 14 - Bus/Frnt/Rmp
0.30 MI15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.WILLIAMS RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.959686
12 - Latitude -91.45777913 - Longitude
DITCH80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
HILL
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
UNKNOWN
117 - Relation To Roadway
DARK-NOT-LIGHTED114 - Light Condition DRY116 - Road Surface Condition CLEAR118 - Weather
Hit and Run
9
Government Property
9
Fire
9
Photos Taken
9
Trailer or Towed
9
Truck, Bus, or Hazardous Materials
9
Load Spillage
9
Construction Zone
9
Names Exchanged
9
Supplemental Reports
101
Witness Statements
102
Measurements Taken
103 79 - E M S Number
Operator/Pedestrian
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Unit Status
DITCH
81 - Most Harmful Event: Collision With
NORTH
23 - Dir Of Travel
4524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2022
31 - Expiration Year 34 - On Duty Accident
JORGENSEN
25 - Operator/Pedestrian Last Name
CODY
25 - First Name
S
25 - Middle Initial 25 - Suffix
02/22
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
HAYWARD
27 - City
WI
27 - State
54843
27 - Zip Code 28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
40 - Safety Equipment
N - NO APPARENT INJURY
38 - Injury Severity
DEPLOYED
41 - Airbag
NOT-EJECTED
42 - Ejected 44
Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
GOING-STRAIGHT
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 062 - No. of Citations Issued
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
OTHER
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDKSV9 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
1
22 - Total Occupants
KN6507
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2016
59 - Exp Year
03287
55 - Vehicle Identification Number
2012
50 - Year
FORD
51 - Make
F150
52 - Model
PK - PICKUP
53 - Body Style
BRZ
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE, MIDDLE DRIVER SIDE, REAR DRIVER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
ROADRUNNER TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
JORGENSEN
46 - Vehicle Owner Last Name
CODY
46 - First Name
S
46 - Middle Initial 46 - Suffix
02/22/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
STATE-FARM63 - Liability Insurance Company Policy Holder Same As Owner60
JORGENSEN
61 - Policy Holder Last Name
CODY
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
01
01
BU
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Trailer
01
TR
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106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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PK2012
Wisconsin Motor Vehicle GZDKSV9 2 424
Fixed Objects Struck
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Property
UNKNOWN
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
84 - Company Name Government Property Type
85 - Address Street & Number 85 - PO Box
86 - City 86 - State 86 - Zip Code 87 - Telephone Number
83 - Government Damage Tag Number
01
82 - Striking Unit
DITCH
82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
105 - Photos By
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Diagram and Narrative
DEPUTY KEVIN GILLIS
VEHICLE WAS TRAVELING NORTH ON HIGHLINE RD. DRIVER FELL ASLEEP AND DROVE INTO THE DITCH APPROXIMATELY 25 FEET
OFF THE ROAD.
VEHICLE WAS TRAVELING NORTH ON HIGHLINE RD. DRIVER FELL ASLEEP AND DROVE INTO THE DITCH APPROXIMATELY 25 FEET
OFF THE ROAD.
Officer Information
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZDKSV9 3 4
OF
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125 - First Name 125 - Middle Initial
GILLIS
125 - Officer Last Name
KEVIN 345
131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
09/26/2015
132 - Date Notified 2327133 - Time Notified (Military Time)2332134 - Time Arrived (Military Time)
09/29/2015
135 - Date Of Report
15092611 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDKSV9 4 4